Medicare payers, under the direction of CMS, reimburse for a variety of telehealth services, but only within carefully defined circumstances. Here are the basics you'll need to know to report telehealth services to Medicare, successfully.
Which Services Are Covered
Currently, CMS limits reimbursement for telehealth services to those represented by approximately 85 CPT and HCPCS Level II codes, including: psychiatric diagnostic procedures (90791-90792); select psychotherapy services (90832-90838); end-stage renal disease services (90951-90952, 90954-90956); outpatient evaluation & management (E/M) services (99201-99215); advanced care planning (99497-99498); annual depression screening (G0444), and more.
The list of Medicare-covered telehealth services is subject to change, each year. For a complete, current list of covered telehealth services, visit the CMS website here.
Covered telehealth services for 2017 also may be found in the Medicare Learning Network, "Rural Health Fact Sheet Series: Telehealth Services." The Telehealth Services Fact Sheet (accessed April 18, 2017) is the source of all quoted material in this article, unless otherwise noted. It can be found here.
The Patient Must Be In an Approved "Originating Site"
For telehealth services billed to Medicare, the patient receiving the service must be in an approved originating site, which CMS defines as, "the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs."
This is a two-part requirement:
First: Per CMS, "beneficiaries are eligible for telehealth services, only if they are presented from an originating site located in a rural Health Professional Shortage Area or in a county outside of a Metropolitan Statistical Area."
A list of Health Professional Shortage Areas, by state and county, may be found on the Department of Health and Human Services Health Resources and Services Administration website (http://hpsafind.hrsa.gov). The U.S. Census maintains a list of Metropolitan Statistical Areas on its website (http://www.census.gov/population/metro/).
Entities that participated in a Federal telemedicine demonstration project prior to Jan. 1, 2001 qualify as originating sites, regardless of geographic location.
Second: An originating site must be of a kind authorized by law, which may include:
• Physician or practitioner office
• Critical Access Hospitals (CAH)
• Rural Health Clinics (RHC)
• Federally Qualified Health Centers (FQHC)
• Skilled Nursing Facilities (SNF)
• Community Mental Health Centers (CMHC)
• Hospital-based or CAH-based Renal Dialysis Centers (including satellites): Independent Renal Dialysis Facilities are not eligible originating sites
Only Approved Providers May Report Telehealth Services
Practitioners who may provide and bill Medicare for telehealth services include:
• Nurse practitioners (NP)
• Physician assistants (PA)
• Nurse midwives
• Clinical nurse specialists (CNS)
• Registered dietitians or nutrition professionals
• Clinical psychologists (CP) and clinical social workers (CSW): however, CMS does not allow CPs and CSWs to bill Medicare for psychiatric diagnostic interview examinations with medical services or medical E/M services, to include 90792 (psychiatric diagnostic evaluation with medical service), 90833 (30-minute psychotherapy add-on code), 90836 (45-minute psychotherapy add-on code), and 90838 (60-minute psychotherapy add-on code).
Services billed must be within a practitioner's scope of practice under applicable state law.
Services Must Be Interactive
CMS rules stipulate that as a condition of payment for telehealth services, providers "…must
use an interactive audio and video telecommunications system that permits real-time communication between [the provider], at the distant site, and the beneficiary, at the originating site. Asynchronous 'store and forward' technology is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii."
In other words, telehealth has to be delivered such that the patient and provider are in constant, two-way communication during the service.
Append Modifier GT to the Claim
When reporting an approved telehealth service, you must append modifier GT via interactive audio and video telecommunications systems to the appropriate service code(s). For example, to bill a level 4 established patient office visit provided via telehealth, report 99214-GT. By appending the modifier, the provider is certifying that the beneficiary was present at an eligible originating site when the telehealth service was furnished.
Special circumstance: When appending modifier GT with a covered end-stage renal disease (ESRD)-related service telehealth code (e.g., 90951 ESRD related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with four or more face-to-face visits by a physician or other qualified health care professional per month), you also are certifying that one visit per month was furnished "hands on" to examine the vascular access site, per the code descriptor requirement.
In those cases (limited to Alaska and Hawaii) when you may bill Medicare for non "face-to-face" telehealth services, report the appropriate code for the professional service with modifier GQ via an asynchronous telecommunications system.
Payment for telehealth services is the same as for services furnished without the use of a telecommunications system.